Intra-aortic Balloon Pump Therapy for Acute Myocardial Infarction AMeta-analysis
Intra-aortic Balloon Pump Therapy for Acute Myocardial Infarction AMeta-analysis
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DOI：
10.1001/jamainternmed.2015.0569
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发表时间：
2015-06-01
影响因子：
39
通讯作者：
Francis, Darrel P.
中科院分区：
文献类型：
--
作者：
Ahmad, Yousif;Sen, Sayan;Francis, Darrel P.
主动脉内球囊反搏（IABP）治疗是一种广泛应用于急性心肌梗死伴心源性休克的介入治疗。指南，以前强烈建议，最近经历了实质性的changes.Objective评估IABP疗效在急性myocardial infarction.DATA SURCES人类研究中发现Pubmed，Embase，和科克伦图书馆通过2014年12月，并在选定的文章的参考列表。检索字符串为“心肌梗死”或“急性冠脉综合征”和“主动脉内球囊反搏”或“反搏”。研究选择随机临床试验（RCTs）和观察性研究，比较急性心肌梗死患者使用IABP和不使用IABP的情况。数据提取和综合两名评价者独立提取数据，并使用科克伦偏倚风险工具评估RCTs中的偏倚风险。我们对随机对照试验和观察性研究进行了单独的荟萃分析。数据采用随机效应荟萃分析进行定量合成。主要结果和指标30天死亡率。结果有12个合格的随机对照试验2123例患者。在RCT中，IABP的使用对死亡率无统计学显著影响（比值比[OR]，0.96 [95% CI，0.74-1.24]），试验间无显著异质性（I-2 = 0%; P = 0.52）。当研究按照心源性休克的存在（OR，0.94 [95%CI，0.69-1.28]; P = 0.69，I-2 = 0%）或不存在（OR，0.98 [95%CI，0.57-1.69]; P = 0.95，I-2 = 17%）进行分层时，该结果是一致的。共有15项合格的观察性研究，共计15530例患者。他们的结果相互矛盾（异质性I-2 = 97%; P <0.001），导致与死亡率相关性的汇总估计存在很大的不确定性（OR，0.96 [95%CI，0.54-1.70]）。观察性研究中基线风险标志物失衡的一个简单指数似乎可以解释观察性数据中的异质性（R-meta（2）= 46.2%; P <0.001）。结论和相关性在随机对照试验中，无论患者是否有心源性休克，使用主动脉内球囊反搏并不能改善急性心肌梗死患者的死亡率。观察性研究显示IABP治疗和死亡率之间存在各种相互矛盾的相关性，其中大部分可通过IABP组和非IABP组之间风险因素平衡的研究差异来解释。
IMPORTANCE Intra-aortic balloon pump (IABP) therapy is a widely used intervention for acute myocardial infarction with cardiogenic shock. Guidelines, which previously strongly recommended it, have recently undergone substantial change.OBJECTIVE To assess IABP efficacy in acute myocardial infarction.DATA SOURCES Human studies found in Pubmed, Embase, and Cochrane libraries through December 2014 and in reference lists of selected articles. Search strings were "myocardial infarction" or "acute coronary syndrome" and "intra-aortic balloon pump" or "counterpulsation."STUDY SELECTION Randomized clinical trials (RCTs) and observational studies comparing use of IABP with no IABP in patients with acute myocardial infarction.DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted the data, and risk of bias in RCTs was assessed using the Cochrane risk of bias tool. We conducted separate meta-analyses of the RCTs and observational studies. Data were quantitatively synthesized using random-effects meta-analysis.MAIN OUTCOMES AND MEASURES Thirty-day mortality.RESULTS There were 12 eligible RCTs randomizing 2123 patients. In the RCTs, IABP use had no statistically significant effect on mortality (odds ratio [OR], 0.96 [95% CI, 0.74-1.24]), with no significant heterogeneity among trials (I-2 = 0%; P = .52). This result was consistent when studies were stratified by the presence (OR, 0.94 [95% CI, 0.69-1.28]; P = .69, I-2 = 0%) or absence (OR, 0.98 [95% CI, 0.57-1.69]; P = .95, I-2 = 17%) of cardiogenic shock. There were 15 eligible observational studies totaling 15 530 patients. Their results were mutually conflicting (heterogeneity I-2 = 97%; P < .001), causing wide uncertainty in the summary estimate for the association with mortality (OR, 0.96 [95% CI, 0.54-1.70]). A simple index of baseline risk marker imbalance in the observational studies appeared to explain much of the heterogeneity in the observational data (R-meta(2) = 46.2%; P < .001).CONCLUSIONS AND RELEVANCE Use of IABP was not found to improve mortality among patients with acute myocardial infarction in the RCTs, regardless of whether patients had cardiogenic shock. The observational studies showed a variety of mutually contradictory associations between IABP therapy and mortality, much of which was explained by the differences between studies in the balance of risk factors between IABP and non-IABP groups.